Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury*

Cremer, Olaf L.; Dijk, Gert W van; Wensen, Erik van; Brekelmans, G. J. F.; Moons, Karel G.M.; Leenen, Loek P. H.; Kalkman, Cor J.

doi:10.1097/01.ccm.0000181300.99078.b5

Cited by 294 publications

(168 citation statements)

References 29 publications

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“…4,5,10,26 There have been numerous studies on the treatment of TBI in the adult population, 4,6,8,9,11,15,16,24,25,29 but less research has been performed on treating TBI in pediatric patients. 2,5,7,18,21,23 These patients' still-maturing CNS responds differently to injury and the current treatments available, making it imperative to determine the best course of action to improve outcomes in this population.…”

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confidence: 99%

Standardizing ICU management of pediatric traumatic brain injury is associated with improved outcomes at discharge

O'Lynnger¹,

Shannon²,

Le³

et al. 2016

Journal of Neurosurgery: Pediatrics

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OBJECT The goal of critical care in treating traumatic brain injury (TBI) is to reduce secondary brain injury by limiting cerebral ischemia and optimizing cerebral blood flow. The authors compared short-term outcomes as defined by discharge disposition and Glasgow Outcome Scale scores in children with TBI before and after the implementation of a protocol that standardized decision-making and interventions among neurosurgeons and pediatric intensivists. METHODS The authors performed a retrospective pre- and postprotocol study of 128 pediatric patients with severe TBI, as defined by Glasgow Coma Scale (GCS) scores < 8, admitted to a tertiary care center pediatric critical care unit between April 1, 2008, and May 31, 2014. The preprotocol group included 99 patients, and the postprotocol group included 29 patients. The primary outcome of interest was discharge disposition before and after protocol implementation, which took place on April 1, 2013. Ordered logistic regression was used to assess outcomes while accounting for injury severity and clinical parameters. Favorable discharge disposition included discharge home. Unfavorable discharge disposition included discharge to an inpatient facility or death. RESULTS Demographics were similar between the treatment periods, as was injury severity as assessed by GCS score (mean 5.43 preprotocol, mean 5.28 postprotocol; p = 0.67). The ordered logistic regression model demonstrated an odds ratio of 4.0 of increasingly favorable outcome in the postprotocol cohort (p = 0.007). Prior to protocol implementation, 63 patients (64%) had unfavorable discharge disposition and 36 patients (36%) had favorable discharge disposition. After protocol implementation, 9 patients (31%) had unfavorable disposition, while 20 patients (69%) had favorable disposition (p = 0.002). In the preprotocol group, 31 patients (31%) died while 6 patients (21%) died after protocol implementation (p = 0.04). CONCLUSIONS Discharge disposition and mortality rates in pediatric patients with severe TBI improved after implementation of a standardized protocol among caregivers based on best-practice guidelines.

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confidence: 99%

Standardizing ICU management of pediatric traumatic brain injury is associated with improved outcomes at discharge

O'Lynnger¹,

Shannon²,

Le³

et al. 2016

Journal of Neurosurgery: Pediatrics

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“…It is notable that clinical outcome-based studies are mixed regarding the impact of ICP monitoring. While protocolized care of severe TBI including ICP monitoring has been reported as beneficial [15], studies suggest that ICP monitoring may be associated with increased mortality [16], greater therapeutic intensity and longer length of stay in the ICU [17]. In light of these caveats, there is sufficient equipoise for a randomized controlled trial to evaluate the effect of an ICP-based algorithm in severe brain injury, in a manner analogous to the way pulmonary artery catheter-guided therapy was tested in acute lung injury [18].…”

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confidence: 99%

Intracranial pressure and its surrogates

Frattalone

Stevens

2011

Intensive Care Med

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Intracranial hypertension [intracranial pressure (ICP) [20 mmHg] is a life-threatening complication seen in a significant proportion of patients following severe traumatic and nontraumatic brain insults [1][2][3]. Sustained elevations in ICP generally signal secondary injury processes such as cerebral edema, hemorrhage, hydrocephalus and ischemia, and as a consequence the management of ICP has become a keystone in neurocritical care. Especially in unresponsive patients when the diagnostic yield of physical examination is limited, temporal trends in ICP can help identify critical changes in intracranial compliance and responses to therapy. Many studies indicate an independent association between the magnitude and duration of ICP elevation and unfavorable outcomes following severe brain injury [2][3][4]. The difference of ICP and mean arterial pressure, cerebral perfusion pressure (CPP), is widely used to infer relationships between systemic circulatory function and cerebral blood flow. Many interventions in brain resuscitation, such as hyperosmolar therapy, sedation, controlled ventilation, and use of vasopressor or inotropic agents, are targeted to ICP and CPP goals. Current guidelines recommend ICP monitoring in patients with severe traumatic brain injury (TBI) who are comatose after resuscitation and who either have abnormalities on cranial computed tomography (CT) scan or meet at least two of the following three criteria: age[40 years; systolic blood pressure \90 mmHg; or motor posturing [5].The gold standard for measuring ICP is via devices placed inside the brain (intraventricular and intraparenchymal monitors). These devices are resource-intensive, carry small but significant risks of infection and hemorrhage, and in the case of intraparenchymal monitors are prone to drift with accuracy declining over time. Alternative methods have been proposed that noninvasively assess ICP through the measurement of a surrogate variable: these include neuroimaging (cranial CT and brain MRI), transcranial Doppler, tympanic membrane displacement, intraocular pressure, venous ophtalmodynanometry, and changes in the optic nerve sheath diameter (ONSD). In this issue of Intensive Care Medicine, Dubourg et al.[6] present a meta-analysis of studies

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“…Nei soggetti individui con TBI grave è necessaria la collocazione di un sensore di pressione intracranica. Inoltre può essere utile, a discrezione del medico curante, considerare il trattamento dell'ipertensione intracranica nei seguenti casi [38][39][40][41][42]:…”

Section: Indicazioni Per Il Monitoraggio Della Pressione Intracranicaunclassified

The first hours of traumatic brain injury. Evaluation and management in emergency room

Piñero¹,

Ferrari²,

Cruzado³

et al. 2014

RHC

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The traumatic brain injury is a common disease worldwide and it represents the leading cause of death and disability in different age groups, with an incidence of particular concern in adolescents and young adults. The Glasgow Coma Scale remains the best method for the initial classification of these patients and to define the route of administration. Since many deaths occur within the first two weeks of the event, it is necessary to optimize the training of health professionals to improve the management of patients with traumatic brain injury and reduce the morbidity and mortality. The primary objective of the first approach is to prevent secondary brain injury and to identify any intracranial lesions that require urgent treatment. The present review aimed to show how to approach to the patients with TBI in Emergency Room. Keywords Traumatic Brain Injury; Emergency Room; Glasgow Coma Scale Valutazione e gestione della lesione cerebrale traumatica al Pronto SoccorsoThe first hours of traumatic brain injury. Evaluation and management in emergency roomNarrative review Disease Reviews in Health Care 2014; 5(3): 117-133 http://dx.doi.org/10. 7175/rhc.v5i3.933 118 Reviews in Health Care 2014; 5(3) © SEEd All rights reserved Valutazione e gestione della lesione cerebrale traumatica al Pronto Soccorso IntroduzioneLa lesione cerebrale traumatica (TBI -Traumatic Brain Injury), più comunemente nota come trauma cranico, è una malattia diffusa in tutto il mondo e rappresenta la principale causa di morte e disabilità in diversi gruppi di età, con un'incidenza particolarmente preoccupante negli adolescenti e nei giovani adulti [1]. I gruppi più colpiti sono i giovani tra i 15 e i 24 anni e gli over 75 [2]. Nai pazienti politraumatizzati, la presenza di TBI aumenta la mortalità, che risulta essere tre volte superiore rispetto alla mortalità per traumi multipli senza coinvolgimento neurologico. La TBI rappresenta un grave problema di salute nei paesi sviluppati e in via di sviluppo per via degli alti costi associati al trattamento acuto, alla riabilitazione e ai costi sociali dovuti agli anni di lavoro persi. I costi economici e sociali sono molto elevati e le conseguenze permanenti sulla personalità e sullo stato mentale possono essere devastanti sia per il paziente sia per i famigliari. La maggior parte dei TBI che si osservano nella pratica clinica quotidiana sono di tipo chiuso, ma una percentuale sempre più in aumento è rappresentata dai TBI aperti di tipo penetrante, solitamente causati da lesioni da arma da fuoco, sia volontarie che accidentali. Gli incidenti stradali sono la causa più comune di trauma cranico chiuso, seguiti dalle cadute. Nei giovani adulti le cause sono per lo più gli incidenti stradali, mentre per i bambini e gli anziani sono le cadute. Il consumo di alcol rappresenta un fattore importante in quasi tutte le cause di trauma cranico e, soprattutto, nei giovani, è presente in circa il 50% dei casi di TBI. Si stima che negli Stati Uniti ogni anno circa 2 milioni di persone subiscano un trauma c...

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Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury*

Abstract: : ICP/CPP-targeted intensive care results in prolonged mechanical ventilation and increased levels of therapy intensity, without evidence for improved outcome in patients who survive beyond 24 hrs following severe head injury.

Cited by 294 publications

References 29 publications

Standardizing ICU management of pediatric traumatic brain injury is associated with improved outcomes at discharge

Standardizing ICU management of pediatric traumatic brain injury is associated with improved outcomes at discharge

Intracranial pressure and its surrogates

The first hours of traumatic brain injury. Evaluation and management in emergency room

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